AIN Blog: Torqued: Maintenance Errors Could Be Fatal
Some days I feel like Richard Clarke the fateful summer before the tragedy of 9/11, when his hair was all on fire as his warnings about the mounting threats by Al Qaeda against the U.S. fell on deaf ears. We all know how that turned out. I feel the same way about the mounting threats to maintenance: from inadequately trained technicians to insufficient oversight by operators and regulators (yes, that’s you, FAA) to the constant pressure to move aircraft as cheaply and quickly as possible. And, of course, the growing concern about the impact of fatigue on the quality of maintenance. The scientific data is beyond dispute: fatigue can and does cause mistakes, by mechanics as by everyone else.
Wherever I go these days, mechanics are tired. Those lucky enough to have kept their jobs are–on average–working longer hours and more days than ever. In part, this is because operators want to do more with less. It is cheaper for them to pay overtime than to hire more mechanics and have to pay them benefits. And mechanics who have had their pay cut from years of givebacks are eagerly taking on overtime and part-time work to maintain their standards of living–which in some cases means staying just two steps ahead of the bill collector.
Fatigue is just as insidious for mechanics as anyone else in transportation. Countless car, bus, truck and train crashes are caused by fatigued drivers. Airplane crashes caused by fatigued pilots grab headlines, but for some reason maintenance fatigue doesn’t grab headlines. Even the 1996 ValuJet accident in which 110 people died in a fiery plunge into the Everglades failed to highlight this critical fact. Could the improper maintenance on the oxygen generator canisters (mechanics failed to install safety caps as required by the maintenance manual) have been caused by over-tired mechanics? I certainly think so.
An interesting fact that never received much public attention was that the repair station’s employees were on mandatory overtime that included extended workdays, seven days a week. Weeks and weeks of mandatory overtime was common at that facility at the time of the maintenance error that led to the improperly packed canisters being placed in the belly of the DC-9. The NTSB concluded that without the safety caps, the oxygen generators were primarily responsible for the resultant fire that ultimately brought down the aircraft.
Extended overtime is common today and has been since the cutbacks that followed 9/11. On top of the increased overtime, layoffs have resulted in a transient population of mechanics, unable to sell their homes and move, forced to live in makeshift arrangements to hold onto any maintenance work they can find. I was stunned to learn from a friend in Los Angeles that a sizeable parking area adjacent to LAX had become home to all manner of airline employees, including mechanics living in their vans and pickup truck campers. I shudder to think of the rest they ever get under such circumstances.
Their situation reminds me of the Air Midwest accident that killed 21 people on takeoff from Charlotte in 2003. The mechanics working on the flight control rigging for the Beech 1900 were similarly long-distance commuters, some even living in their pickup trucks. Could their lack of rest have contributed to the maintenance error that resulted in the rigging having too much nose-up authority and not enough nose down, which meant that the pilot was unable to prevent the tail-heavy aircraft from stalling? Clearly, flight controls are one of the most critical systems on an aircraft and require concentration and focused attention that are often casualties of fatigue.
Limited FAA Action
Unfortunately, the airlines and repair stations have largely turned a blind eye and deaf ear to the maintenance fatigue issues. So where is the FAA, the safety regulator? To its credit, it has been studying the issue. Several years ago, it formed a Maintenance Fatigue Working Group, in which I have been pleased to participate. Led by a recognized fatigue research scientist, the group has brought scientific rigor to a complex science. But, unfortunately, progress toward a duty and rest rule for all mechanics has been painfully slow. The FAA frequently dithers when issues are complex. While I grant you that the issues are complex, they are not too complex for rulemaking.
I give the agency credit for realizing that something needed to be done. With a rule in the far distant future, the FAA made a laudable attempt to address the critical fatigue issue for airline mechanics by revisiting its interpretation of duty and rest for maintenance workers in FAR Section 121.377. Reversing a prior interpretation, the FAA’s new interpretation would require airline and repair station employees who perform airline maintenance to have 24 consecutive hours of rest in any seven-day period, except for emergencies. Although it does not limit the number of hours maintenance personnel can work in a day–16-hour days, incredibly, are not unheard of–it does at least provide some mandatory rest in a seven-day period.
It seems that even this meager concession to fatigue prevention has been met with opposition from expected and unexpected corners of the aviation industry. It’s not surprising that the repair station association asked the FAA to reconsider its interpretation. After all, the economic interests of their members may well trump the safety benefits of a well rested workforce in their eyes. Somewhat more unexpected–although economically understandable–has been the opposition of mechanics working the overtime to any decrease in their hours.
The FAA needs to stand firmly by its current maintenance duty and rest interpretation of FAR Section 121.377. It’s such a small–but critically important–step in the right direction for air safety. Fatigued maintenance workers cannot be relied upon to perform maintenance properly. I hope that for once the FAA has the backbone to stand up for what is right for the travelling public even in the face of broad-based opposition.